Biopolitics, Risk and Organization in Health Care Gianpasquale Preite

JDREAM (2017), v. 1 i. 1, 81-88 ISSN 2532-7518

DOI 10.1285/i25327518v1i1p81

http://siba-ese.unisalento.it, © 2017 Università del Salento

81

Biopolitics, Risk and Organization in Health Care Gianpasquale Preite

Department of History, Society and Human Studies, University of Salento, Italy gianpasquale.preite@unisalento.it

Abstract

The study and analysis of the organization in health care depends on some aspects that include the observation of social phenomena, law categories, and political strategies as well as the administrative behaviors. All these as-pects have led to the overcoming of the traditional concept of bureaucracy, which finds a solid theoretical foun-dation in the studies undertaken by Weber. In the Weber's vision, bureaucracy is the organization of people and resources for a collective purpose, public, according to any criteria of rationality, impartiality and impersonality. The assumption is that it is hard to perceive organizations oriented towards an end in a rational way, unless as bureaucracies, even considering that there may be non-bureaucratic organizational forms, not rationally oriented to a purpose (Weber 1922). One of the most original contributions of the late twentieth century comes from Luhmann's theory of social systems that is applied to the concept of organization. It provides an understanding of the object that goes beyond tautological assumptions (e.g. the organization is composed of men) and that permits to talk about organization as autopoietic system, not "closed" but "operationally closed" and therefore independent on the structural and operational plan (Luhmann 2000, 29-30). In the theory of systems - although the organizations may arise freely – what is defined as "complex" organizations, are formed within functions sys-tems distinguished in economic organizations, political organizations, trade union organizations, health care or-ganizations, etc. Main features include the possibility that they have to communicate with other systems in their environment (Luhmann and De Giorgi 1994, 328) and the reduction of uncertainty and risk. The absorption of uncertainty occurs when an organization elaborates some decisions that are a prerequisite for other decisions. In the social systems theory, all the organization activities are classified as decisions, take place at a given time, and are always documented. However, the evolutionary path that is used to trace the organizational profiles of com-plex apparatus cannot ignore the importance of Kuhn's theory, according to which scientific revolutions are characterized by the transition from one paradigm to another (Kuhn, 1999). The application of this latter model to the public organizations, permits to understand that even these organizations are subjected to the dynamics of cultural paradigms, according to which the transition from one paradigm - that no longer recognizes the organi-zations themselves - to another one, that rather includes new models, methods and practices, definitely involves a revolution (Limone 2008, 17). In order to properly talk about organization and e-government, especially in the health and medical sector, we first need to verify the most suitable organizational context able to manage innova-tion soluinnova-tions and, therefore, analyze the organizainnova-tional condiinnova-tions as a prerequisite for the technological condi-tions. In fact, if the organizational environment does not respond to concrete parameters such as transparency, efficiency and economy, even the same e-government process is likely to fail. That is the only viable way to ra-tionalizing and improving the public organizational system, such as health care systems, that tend to have high level of complexity and risk due to their nature.

Keywords: organization; risk; health care; integrated governance

1. Introduction: historical and evolutionary trails

The organization of the current complex struc-tures - in particular the organization of health care facilities - depends on some aspects that

include the observation of social phenomena, law categories, and political strategies as well as the administrative behaviors. All these aspects have led to the overcoming of the traditional concept of bureaucracy, which finds a solid

JDREAM. Journal of interDisciplinary REsearch Applied to Medicine JDREAM (2017), v. 1 i. 1, 81-88

ISSN 2532-7518

DOI 10.1285/i25327518v1i1p81

http://siba-ese.unisalento.it, © 2017 Università del Salento

81

Biopolitics, Risk and Organization in Health Care Gianpasquale Preite

Department of History, Society and Human Studies, University of Salento, Italy gianpasquale.preite@unisalento.it

Abstract

The study and analysis of the organization in health care, depends on some aspects that include the observation of social phenomena, law categories, and political strategies as well as the administrative behaviors. All these as-pects have led to the overcoming of the traditional concept of bureaucracy, which finds a solid theoretical foun-dation in the studies undertaken by Weber. In the Weber's vision, bureaucracy is the organization of people and resources for a collective purpose, public, according to any criteria of rationality, impartiality and impersonality. The assumption is that it is hard to perceive organizations oriented towards an end in a rational way, unless as bureaucracies, even considering that there may be non-bureaucratic organizational forms, not rationally oriented to a purpose (Weber 1922). One of the most original contributions of the late twentieth century comes from Luhmann's theory of social systems that is applied to the concept of organization. It provides an understanding of the object that goes beyond tautological assumptions (e.g. the organization is composed of men) and that permits to talk about organization as autopoietic system, not "closed" but "operationally closed" and therefore independent on the structural and operational plan (Luhmann 2000, 29-30). In the theory of systems - although the organizations may arise freely – what is defined as "complex" organizations, are formed within functions sys-tems distinguished in economic organizations, political organizations, trade union organizations, health care or-ganizations, etc. Main features include the possibility that they have to communicate with other systems in their environment (Luhmann and De Giorgi 1994, 328) and the reduction of uncertainty and risk. The absorption of uncertainty occurs when an organization elaborates some decisions that are a prerequisite for other decisions. In the social systems theory, all the organization activities are classified as decisions, take place at a given time, and are always documented. However, the evolutionary path that is used to trace the organizational profiles of com-plex apparatus cannot ignore the importance of Kuhn's theory, according to which scientific revolutions are characterized by the transition from one paradigm to another (Kuhn, 1999). The application of this latter model to the public organizations, permits to understand that even these organizations are subjected to the dynamics of cultural paradigms, according to which the transition from one paradigm - that no longer recognizes the organi-zations themselves - to another one, that rather includes new models, methods and practices, definitely involves a revolution (Limone 2008, 17). In order to properly talk about organization and e-government, especially in the health and medical sector, we first need to verify the most suitable organizational context able to manage innova-tion soluinnova-tions and, therefore, analyze the organizainnova-tional condiinnova-tions as a prerequisite for the technological condi-tions. In fact, if the organizational environment does not respond to concrete parameters such as transparency, efficiency and economy, even the same e-government process is likely to fail. That is the only viable way to ra-tionalizing and improving the public organizational system, such as health care systems, that tend to have high level of complexity and risk due to their nature.

Keywords: organization; risk; health care; integrated governance

1. Introduction: historical and evolutionary trails

The organization of the current complex struc-tures - in particular the organization of health care facilities - depends on some aspects that

Biopolitics, Risk and Organization in Health Care

82

theoretical foundation in the studies undertaken by Weber.

In the Weber's vision, bureaucracy is the organ-ization of people and resources for a collective purpose, public, according to any criteria of ra-tionality, impartiality and impersonality. The as-sumption is that it is hard to perceive organiza-tions oriented towards an end in a rational way, unless as bureaucracies, even considering that there may be non-bureaucratic organizational forms, not rationally oriented to a purpose (Weber 1922).

The Weber's studies have been developed later on through the contributions of Merton, alt-hough with different epistemological assump-tions. Merton envisions his model by perform-ing an ambivalent step: a) on one hand, he criti-cizes the rationality concept of bureaucracy in the Weberian model by using a functional ap-proach; b) on the other side, he retrieves some elements of Weberian analysis for making criti-cism on his ideal model. In addition, Merton makes a distinction between the overt functions and the latent functions. Only with the analysis of latent functions, he shows that the Weber's model contains some sources of irrationality even with respect to the purpose, which do not consist in deficiencies in organizational design, but in the unforeseen effects that the pressure exerted by structures can provoke on the per-sonality and behavior of men (Merton 1968). In the seventies, Gouldner makes a change in the rules of Merton's scheme in tayloristic terms: he adopted a critical functionalism on the distinction between manifest and latent functions, able to identify the latent functions of measures, norms and institutions (Gouldner 1973). He identifies three key regulatory models of the bureaucratic action: a) the apparent bu-reaucracy, which occurs when both the direc-tors and the employees have indifference atti-tude towards the respect of a rule imposed by an outside authority; b) representative bureau-cracy, which occurs when both the directors and employees agree on the usefulness of ob-serving certain rules; c) the taxation bureaucra-cy, which occurs when the rules are imposed from one side against the will of the others (Bonazzi, 2008, 232-235).

The Selznick's theoretical model, developed

through a structural-functional analysis (critical

functionalism between Parsons and Merton), shows a

theoretical method that is intended to have general validity for any formal organization which has an internal bureaucracy. In particular,

he introduces The institute of cooptation (defined as

the process of absorption of new elements in the structure that determine the organization policy, as a way for preventing threats to its stability or existence) and performing, then, a further distinction between formal cooptation and informal or substantial cooptation (Selz-nick, 1969).

Crozier is primarily interested in some aspects such as safety, regularity and the impersonality of the functioning that are only found in the public administration entities. The issue that arises regards the functioning of such organiza-tions and the social relaorganiza-tions that exist within it, moving away from the post-Weberian func-tionalisms when they consider the difficulties of the change in bureaucratic organizations and when they highlight the relationship between technological innovation opportunities and the growing autonomy and cultural sophistication of individuals. In particular, (Crozier 1994, 22-27) Crozier carries out a pejorative interpreta-tion of bureaucracy term: he conducts a strate-gic analysis of bureaucratic behaviors and de-fines power as control of uncertainty, highlight-ing the importance of National cultural models (Bonazzi 2008, 266-273).

In the eighties, the overcoming of the tradition-al bureaucracy was mainly defined by the mana-gerial literature attributed to the studies of Drucker and Mintzberg, in which the "man-agement by aims" model proposed by Drucker (Ivi, 287), may be viewed as specular antithesis of the traditional Weber’s conception of bu-reaucracy. In this model, they provide an open debate beyond the hierarchies; the identification and negotiation of aims; the personalization of social relations; the acquisition of skills on the field; mobility in the career path and the majori-ty attention given to the purpose rather than to the norms, as well as a form of "competitive democracy" at the workplace (Ivi, 292). All the-se factors result in a complete reversal of the axioms of the traditional Weberian model. One of the most original contributions of the late twentieth century comes from Luhmann's theory of social systems that is applied to the concept of organization. It provides an under-standing of the object that goes beyond

tauto-Biopolitics, Risk and Organization in Health Care

82

theoretical foundation in the studies undertaken by Weber.

In the Weber's vision, bureaucracy is the organ-ization of people and resources for a collective purpose, public, according to any criteria of ra-tionality, impartiality and impersonality. The as-sumption is that it is hard to perceive organiza-tions oriented towards an end in a rational way, unless as bureaucracies, even considering that there may be non-bureaucratic organizational forms, not rationally oriented to a purpose (Weber 1922).

The Weber's studies have been developed later on through the contributions of Merton, alt-hough with different epistemological assump-tions. Merton envisions his model by perform-ing an ambivalent step: a) on one hand, he criti-cizes the rationality concept of bureaucracy in the Weberian model by using a functional ap-proach; b) on the other side, he retrieves some elements of Weberian analysis for making criti-cism on his ideal model. In addition, Merton makes a distinction between the overt functions and the latent functions. Only with the analysis of latent functions, he shows that the Weber's model contains some sources of irrationality even with respect to the purpose, which do not consist in deficiencies in organizational design, but in the unforeseen effects that the pressure exerted by structures can provoke on the per-sonality and behavior of men (Merton 1968). In the seventies, Gouldner makes a change in the rules of Merton's scheme in tayloristic terms: he adopted a critical functionalism on the distinction between manifest and latent functions, able to identify the latent functions of measures, norms and institutions (Gouldner 1973). He identifies three key regulatory models of the bureaucratic action: a) the apparent bu-reaucracy, which occurs when both the direc-tors and the employees have indifference atti-tude towards the respect of a rule imposed by an outside authority; b) representative bureau-cracy, which occurs when both the directors and employees agree on the usefulness of ob-serving certain rules; c) the taxation bureaucra-cy, which occurs when the rules are imposed from one side against the will of the others (Bonazzi, 2008, 232-235).

The Selznick's theoretical model, developed

through a structural-functional analysis (critical

functionalism between Parsons and Merton), shows a

theoretical method that is intended to have general validity for any formal organization which has an internal bureaucracy. In particular,

he introduces The institute of cooptation (defined as

the process of absorption of new elements in the structure that determine the organization policy, as a way for preventing threats to its stability or existence) and performing, then, a further distinction between formal cooptation and informal or substantial cooptation (Selz-nick, 1969).

Crozier is primarily interested in some aspects such as safety, regularity and the impersonality of the functioning that are only found in the public administration entities. The issue that arises regards the functioning of such organiza-tions and the social relaorganiza-tions that exist within it, moving away from the post-Weberian func-tionalisms when they consider the difficulties of the change in bureaucratic organizations and when they highlight the relationship between technological innovation opportunities and the growing autonomy and cultural sophistication of individuals. In particular, (Crozier 1994, 22-27) Crozier carries out a pejorative interpreta-tion of bureaucracy term: he conducts a strate-gic analysis of bureaucratic behaviors and de-fines power as control of uncertainty, highlight-ing the importance of National cultural models (Bonazzi 2008, 266-273).

In the eighties, the overcoming of the tradition-al bureaucracy was mainly defined by the mana-gerial literature attributed to the studies of Drucker and Mintzberg, in which the "man-agement by aims" model proposed by Drucker (Ivi, 287), may be viewed as specular antithesis of the traditional Weber’s conception of bu-reaucracy. In this model, they provide an open debate beyond the hierarchies; the identification and negotiation of aims; the personalization of social relations; the acquisition of skills on the field; mobility in the career path and the majori-ty attention given to the purpose rather than to the norms, as well as a form of "competitive democracy" at the workplace (Ivi, 292). All the-se factors result in a complete reversal of the axioms of the traditional Weberian model. One of the most original contributions of the late twentieth century comes from Luhmann's theory of social systems that is applied to the concept of organization. It provides an under-standing of the object that goes beyond

tauto-JDREAM.indd 82 18/01/18 11:03

82

theoretical foundation in the studies undertaken by Weber.

In the Weber's vision, bureaucracy is the organ-ization of people and resources for a collective purpose, public, according to any criteria of ra-tionality, impartiality and impersonality. The as-sumption is that it is hard to perceive organiza-tions oriented towards an end in a rational way, unless as bureaucracies, even considering that there may be non-bureaucratic organizational forms, not rationally oriented to a purpose (Weber 1922).

The Weber's studies have been developed later on through the contributions of Merton, alt-hough with different epistemological assump-tions. Merton envisions his model by perform-ing an ambivalent step: a) on one hand, he criti-cizes the rationality concept of bureaucracy in the Weberian model by using a functional ap-proach; b) on the other side, he retrieves some elements of Weberian analysis for making criti-cism on his ideal model. In addition, Merton makes a distinction between the overt functions and the latent functions. Only with the analysis of latent functions, he shows that the Weber's model contains some sources of irrationality even with respect to the purpose, which do not consist in deficiencies in organizational design, but in the unforeseen effects that the pressure exerted by structures can provoke on the per-sonality and behavior of men (Merton 1968). In the seventies, Gouldner makes a change in the rules of Merton's scheme in tayloristic terms: he adopted a critical functionalism on the distinction between manifest and latent functions, able to identify the latent functions of measures, norms and institutions (Gouldner 1973). He identifies three key regulatory models of the bureaucratic action: a) the apparent bu-reaucracy, which occurs when both the direc-tors and the employees have indifference atti-tude towards the respect of a rule imposed by an outside authority; b) representative bureau-cracy, which occurs when both the directors and employees agree on the usefulness of ob-serving certain rules; c) the taxation bureaucra-cy, which occurs when the rules are imposed from one side against the will of the others (Bonazzi, 2008, 232-235).

The Selznick's theoretical model, developed

through a structural-functional analysis (critical

functionalism between Parsons and Merton), shows a

theoretical method that is intended to have general validity for any formal organization which has an internal bureaucracy. In particular,

he introduces The institute of cooptation (defined as

the process of absorption of new elements in the structure that determine the organization policy, as a way for preventing threats to its stability or existence) and performing, then, a further distinction between formal cooptation and informal or substantial cooptation (Selz-nick, 1969).

Crozier is primarily interested in some aspects such as safety, regularity and the impersonality of the functioning that are only found in the public administration entities. The issue that arises regards the functioning of such organiza-tions and the social relaorganiza-tions that exist within it, moving away from the post-Weberian func-tionalisms when they consider the difficulties of the change in bureaucratic organizations and when they highlight the relationship between technological innovation opportunities and the growing autonomy and cultural sophistication of individuals. In particular, (Crozier 1994, 22-27) Crozier carries out a pejorative interpreta-tion of bureaucracy term: he conducts a strate-gic analysis of bureaucratic behaviors and de-fines power as control of uncertainty, highlight-ing the importance of National cultural models (Bonazzi 2008, 266-273).

In the eighties, the overcoming of the tradition-al bureaucracy was mainly defined by the mana-gerial literature attributed to the studies of Drucker and Mintzberg, in which the "man-agement by aims" model proposed by Drucker (Ivi, 287), may be viewed as specular antithesis of the traditional Weber’s conception of bu-reaucracy. In this model, they provide an open debate beyond the hierarchies; the identification and negotiation of aims; the personalization of social relations; the acquisition of skills on the field; mobility in the career path and the majori-ty attention given to the purpose rather than to the norms, as well as a form of "competitive democracy" at the workplace (Ivi, 292). All the-se factors result in a complete reversal of the axioms of the traditional Weberian model. One of the most original contributions of the late twentieth century comes from Luhmann's theory of social systems that is applied to the concept of organization. It provides an under-standing of the object that goes beyond

tauto-83

logical assumptions (e.g. the organization is composed of men) and that permits to talk about organization as autopoietic system, not "closed" but "operationally closed" and there-fore independent on the structural and opera-tional plan (Luhmann 2000, 29-30). In the theo-ry of systems - although the organizations may arise freely – what is defined as "complex" or-ganizations, are formed within functions sys-tems distinguished in economic organizations, political organizations, trade union organiza-tions, health care organizaorganiza-tions, etc. Main fea-tures include the possibility that they have to communicate with other systems in their envi-ronment (Luhmann and De Giorgi 1994, 328) and the reduction of uncertainty and risk. The absorption of uncertainty occurs when an or-ganization elaborates some decisions that are a prerequisite for other decisions. In the social systems theory, all the organization activities are classified as decisions, take place at a given time, and are always documented.

However, the evolutionary path that is used to trace the organizational profiles of complex ap-paratus cannot ignore the importance of Kuhn's theory, according to which scientific revolutions are characterized by the transition from one paradigm to another (Kuhn, 1999). The application of this latter model to the pub-lic organizations, permits to understand that even these organizations are subjected to the dynamics of cultural paradigms, according to which the transition from one paradigm - that no longer recognizes the organizations them-selves - to another one, that rather includes new models, methods and practices, definitely in-volves a revolution (Limone 2008, 17). In order to properly talk about organization and e-government, especially in the health and medi-cal sector, we first need to verify the most suit-able organizational context suit-able to manage in-novation solutions and, therefore, analyze the organizational conditions as a prerequisite for the technological conditions. In fact, if the or-ganizational environment does not respond to concrete parameters such as transparency, effi-ciency and economy, even the same e-government process is likely to fail.

The building blocks of the new paradigm reveal the need to pay attention to the reorganization of structures and internal functions (back-office) even before external activities (front

of-fice). The systematic intervention on the back-office ensures, in fact, that technological inno-vation is the same for the front office. That is the only viable way to rationalizing and improv-ing the public organizational system, such as health care systems, that tend to have high level of complexity and risk due to their nature. 2. Organization in health: risk and quality

The concept of clinical governance was born in England, in the late nineties of the last century, within the politics of organizational strategies and regulatory system of the British National Health Service (NHS). The adoption of this concept comes from the first interventions on the quality management of health services that is meant as institutional duty shared among clinical professionals, experts in organization, health professionals and, in particular, policy makers. In the philosophy of clinical govern-ance - according to NHS's guidelines largely ac-cepted by our National Health System (SSN), organizations are responsible for the continu-ous improvement of the quality of their services and the safeguarding of elevated standards of care, through the creation of an environment in which the excellence in clinical care need to flourish (NHS, Department of Health, 1998).

The clinical governance can be considered as a new expression that may change the cultural system totally. In these terms, it provides re-sources to develop organizational skills ori-ented on sustainable health care, focused on patient, along with guaranteed quality that is necessary for the different stakeholders. In this perspective:

∙ Patients needs are in the spotlight of clini-cians and administrators, who take shared re-sponsibility,

∙ Information related to the quality of services are available to professionals, patients and the public,

∙ Differences in performance access, care pro-cesses and clinical results are measured with the continued commitment to reduce them, ∙ All organizations work together to continu-ously improve service quality,

∙ Professionals work as a team to deliver bet-ter performance in bet-terms of clinical outcomes and safety,

82

theoretical foundation in the studies undertaken by Weber.

In the Weber's vision, bureaucracy is the organ-ization of people and resources for a collective purpose, public, according to any criteria of ra-tionality, impartiality and impersonality. The as-sumption is that it is hard to perceive organiza-tions oriented towards an end in a rational way, unless as bureaucracies, even considering that there may be non-bureaucratic organizational forms, not rationally oriented to a purpose (Weber 1922).

The Weber's studies have been developed later on through the contributions of Merton, alt-hough with different epistemological assump-tions. Merton envisions his model by perform-ing an ambivalent step: a) on one hand, he criti-cizes the rationality concept of bureaucracy in the Weberian model by using a functional ap-proach; b) on the other side, he retrieves some elements of Weberian analysis for making criti-cism on his ideal model. In addition, Merton makes a distinction between the overt functions and the latent functions. Only with the analysis of latent functions, he shows that the Weber's model contains some sources of irrationality even with respect to the purpose, which do not consist in deficiencies in organizational design, but in the unforeseen effects that the pressure exerted by structures can provoke on the per-sonality and behavior of men (Merton 1968). In the seventies, Gouldner makes a change in the rules of Merton's scheme in tayloristic terms: he adopted a critical functionalism on the distinction between manifest and latent functions, able to identify the latent functions of measures, norms and institutions (Gouldner 1973). He identifies three key regulatory models of the bureaucratic action: a) the apparent bu-reaucracy, which occurs when both the direc-tors and the employees have indifference atti-tude towards the respect of a rule imposed by an outside authority; b) representative bureau-cracy, which occurs when both the directors and employees agree on the usefulness of ob-serving certain rules; c) the taxation bureaucra-cy, which occurs when the rules are imposed from one side against the will of the others (Bonazzi, 2008, 232-235).

The Selznick's theoretical model, developed

through a structural-functional analysis (critical

functionalism between Parsons and Merton), shows a

theoretical method that is intended to have general validity for any formal organization which has an internal bureaucracy. In particular,

he introduces The institute of cooptation (defined as

the process of absorption of new elements in the structure that determine the organization policy, as a way for preventing threats to its stability or existence) and performing, then, a further distinction between formal cooptation and informal or substantial cooptation (Selz-nick, 1969).

Crozier is primarily interested in some aspects such as safety, regularity and the impersonality of the functioning that are only found in the public administration entities. The issue that arises regards the functioning of such organiza-tions and the social relaorganiza-tions that exist within it, moving away from the post-Weberian func-tionalisms when they consider the difficulties of the change in bureaucratic organizations and when they highlight the relationship between technological innovation opportunities and the growing autonomy and cultural sophistication of individuals. In particular, (Crozier 1994, 22-27) Crozier carries out a pejorative interpreta-tion of bureaucracy term: he conducts a strate-gic analysis of bureaucratic behaviors and de-fines power as control of uncertainty, highlight-ing the importance of National cultural models (Bonazzi 2008, 266-273).

In the eighties, the overcoming of the tradition-al bureaucracy was mainly defined by the mana-gerial literature attributed to the studies of Drucker and Mintzberg, in which the "man-agement by aims" model proposed by Drucker (Ivi, 287), may be viewed as specular antithesis of the traditional Weber’s conception of bu-reaucracy. In this model, they provide an open debate beyond the hierarchies; the identification and negotiation of aims; the personalization of social relations; the acquisition of skills on the field; mobility in the career path and the majori-ty attention given to the purpose rather than to the norms, as well as a form of "competitive democracy" at the workplace (Ivi, 292). All the-se factors result in a complete reversal of the axioms of the traditional Weberian model. One of the most original contributions of the late twentieth century comes from Luhmann's theory of social systems that is applied to the concept of organization. It provides an under-standing of the object that goes beyond

tauto-83

logical assumptions (e.g. the organization is composed of men) and that permits to talk about organization as autopoietic system, not "closed" but "operationally closed" and there-fore independent on the structural and opera-tional plan (Luhmann 2000, 29-30). In the theo-ry of systems - although the organizations may arise freely – what is defined as "complex" or-ganizations, are formed within functions sys-tems distinguished in economic organizations, political organizations, trade union organiza-tions, health care organizaorganiza-tions, etc. Main fea-tures include the possibility that they have to communicate with other systems in their envi-ronment (Luhmann and De Giorgi 1994, 328) and the reduction of uncertainty and risk. The absorption of uncertainty occurs when an or-ganization elaborates some decisions that are a prerequisite for other decisions. In the social systems theory, all the organization activities are classified as decisions, take place at a given time, and are always documented.

However, the evolutionary path that is used to trace the organizational profiles of complex ap-paratus cannot ignore the importance of Kuhn's theory, according to which scientific revolutions are characterized by the transition from one paradigm to another (Kuhn, 1999). The application of this latter model to the pub-lic organizations, permits to understand that even these organizations are subjected to the dynamics of cultural paradigms, according to which the transition from one paradigm - that no longer recognizes the organizations them-selves - to another one, that rather includes new models, methods and practices, definitely in-volves a revolution (Limone 2008, 17). In order to properly talk about organization and e-government, especially in the health and medi-cal sector, we first need to verify the most suit-able organizational context suit-able to manage in-novation solutions and, therefore, analyze the organizational conditions as a prerequisite for the technological conditions. In fact, if the or-ganizational environment does not respond to concrete parameters such as transparency, effi-ciency and economy, even the same e-government process is likely to fail.

The building blocks of the new paradigm reveal the need to pay attention to the reorganization of structures and internal functions (back-office) even before external activities (front

of-fice). The systematic intervention on the back-office ensures, in fact, that technological inno-vation is the same for the front office. That is the only viable way to rationalizing and improv-ing the public organizational system, such as health care systems, that tend to have high level of complexity and risk due to their nature. 2. Organization in health: risk and quality

The concept of clinical governance was born in England, in the late nineties of the last century, within the politics of organizational strategies and regulatory system of the British National Health Service (NHS). The adoption of this concept comes from the first interventions on the quality management of health services that is meant as institutional duty shared among clinical professionals, experts in organization, health professionals and, in particular, policy makers. In the philosophy of clinical govern-ance - according to NHS's guidelines largely ac-cepted by our National Health System (SSN), organizations are responsible for the continu-ous improvement of the quality of their services and the safeguarding of elevated standards of care, through the creation of an environment in which the excellence in clinical care need to flourish (NHS, Department of Health, 1998).

The clinical governance can be considered as a new expression that may change the cultural system totally. In these terms, it provides re-sources to develop organizational skills ori-ented on sustainable health care, focused on patient, along with guaranteed quality that is necessary for the different stakeholders. In this perspective:

∙ Patients needs are in the spotlight of clini-cians and administrators, who take shared re-sponsibility,

∙ Information related to the quality of services are available to professionals, patients and the public,

∙ Differences in performance access, care pro-cesses and clinical results are measured with the continued commitment to reduce them, ∙ All organizations work together to continu-ously improve service quality,

Biopolitics, Risk and Organization in Health Care

84

∙ The risks and dangers to patients are brought to the lowest level,

∙ Health care is based on evidence and on good clinical practice.

According to this approach, the concept of clinical governance implies that the manage-ment of power takes place inside and outside the formal decision tree; these decisions arise from the interaction between the various stake-holders. Any person involved in the process becomes the bearer of specific needs and ex-pectations, different scale of priorities and dif-ferent capacity of perception of the results ob-tained (Wright, Hill 2005, 22-23). However, it is interesting to observe that once it is stabilized the process of clinical governance, the problem becomes its integration with all the other ele-ments that constitute the different aspects of the management of health care organizations. Integrated governance is a further concept in-troduced for the first time in England in 2003, with the document entitled: "Governing the NHS: a Guide for NHS Boards (NHS Ap-pointment Commission, 2003). The aim of this document is the integration of the different sec-toral systems of governance (health, clinic, fi-nancial, management, research and infmation) and delete the existing overlays, in or-der to standardize (harmonize) different basal processes. The need for an integrated approach is based on the recognition that working for sectors - in a not shared way - is scattered and unproductive, so it is necessary to develop a unifying methodology that helps the organiza-tions to realize their mission and reach the ob-jectives (Wall, Halligan, Deighan, Cullen, 2002). The concept of integrated governance goes be-yond the corporate governance that is defined as the set of rules and organizational structures by which companies are managed and con-trolled. Health facilities (especially public ones) are considered as a constellation of several complex systems: there is the system of hospital care and the one related to primary care, the system of professional clinicians, and the one of professionals in organization, the system of the most important centers and the one in periph-eries (Wright, Hill, 2005, 25).

The management philosophy of integrated gov-ernance also includes risk management, a methodology employed in health care settings but derived from the financial sector and that,

in essence, involves the management of all those risks that threaten the value of an organi-zation and that involve different aspects and different dimensions of organizational phe-nomenon: strategies, market processes, financial resources, human resources, technologies. However, the application of this methodology in the field of health care, cannot collapse in the

transfer sic et nunc of principles and techniques

designed in the industrial sector, financial or of the ICT (Novaco 2004, 24), although it is clear that even a health care company must deal with many risks that go beyond a particular risk and encompassing any general risks that any organi-zation, regardless of the sector to which they belong, must know how to manage in terms of total quality.

Literature on organization, mainly from North American, was concerned to provide the defini-tion of quality in health care systems and to draw up specific models (Donabedian 1966; Devlin 1990; Charlesworth 1993, 25). In 1984, Maxwell developed a model that includes six fundamental dimensions aimed to obtain effi-cient and effective level of quality in health care: 1) access to services; 2) the significance of collective needs (of the community); 3) the practical effectiveness for the "person" (indi-vidual patients); 4) the fairness and impartiality in the treatment; 5) social acceptability of the service supply; 6) the efficiency and economy of the service rendered (Maxwell, 1984, 1470-1472).

The study of Maxwell can be considered suita-ble for responding to the following questions:

a. Is the service physically and temporally

acces-sible to the persons to whom it is addressed (in terms of physical accessibility and time)?

b. Do services, processes and procedures reflect

the community and individual needs?

c. Does every single service allow obtaining the

benefits or providing desired outcomes for in-dividuals or groups of patients?

d. Is the service provided in an unbiased

man-ner between the various categories or groups of patients?

e. Are the conditions for the provision of the

service, the level of protection of privacy, the communication grade with patients, families and assistance team satisfactory?

Biopolitics, Risk and Organization in Health Care

84

∙ The risks and dangers to patients are brought to the lowest level,

∙ Health care is based on evidence and on good clinical practice.

According to this approach, the concept of clinical governance implies that the manage-ment of power takes place inside and outside the formal decision tree; these decisions arise from the interaction between the various stake-holders. Any person involved in the process becomes the bearer of specific needs and ex-pectations, different scale of priorities and dif-ferent capacity of perception of the results ob-tained (Wright, Hill 2005, 22-23). However, it is interesting to observe that once it is stabilized the process of clinical governance, the problem becomes its integration with all the other ele-ments that constitute the different aspects of the management of health care organizations. Integrated governance is a further concept in-troduced for the first time in England in 2003, with the document entitled: "Governing the NHS: a Guide for NHS Boards (NHS Ap-pointment Commission, 2003). The aim of this document is the integration of the different sec-toral systems of governance (health, clinic, fi-nancial, management, research and infmation) and delete the existing overlays, in or-der to standardize (harmonize) different basal processes. The need for an integrated approach is based on the recognition that working for sectors - in a not shared way - is scattered and unproductive, so it is necessary to develop a unifying methodology that helps the organiza-tions to realize their mission and reach the ob-jectives (Wall, Halligan, Deighan, Cullen, 2002). The concept of integrated governance goes be-yond the corporate governance that is defined as the set of rules and organizational structures by which companies are managed and con-trolled. Health facilities (especially public ones) are considered as a constellation of several complex systems: there is the system of hospital care and the one related to primary care, the system of professional clinicians, and the one of professionals in organization, the system of the most important centers and the one in periph-eries (Wright, Hill, 2005, 25).

The management philosophy of integrated gov-ernance also includes risk management, a methodology employed in health care settings but derived from the financial sector and that,

in essence, involves the management of all those risks that threaten the value of an organi-zation and that involve different aspects and different dimensions of organizational phe-nomenon: strategies, market processes, financial resources, human resources, technologies. However, the application of this methodology in the field of health care, cannot collapse in the

transfer sic et nunc of principles and techniques

designed in the industrial sector, financial or of the ICT (Novaco 2004, 24), although it is clear that even a health care company must deal with many risks that go beyond a particular risk and encompassing any general risks that any organi-zation, regardless of the sector to which they belong, must know how to manage in terms of total quality.

Literature on organization, mainly from North American, was concerned to provide the defini-tion of quality in health care systems and to draw up specific models (Donabedian 1966; Devlin 1990; Charlesworth 1993, 25). In 1984, Maxwell developed a model that includes six fundamental dimensions aimed to obtain effi-cient and effective level of quality in health care: 1) access to services; 2) the significance of collective needs (of the community); 3) the practical effectiveness for the "person" (indi-vidual patients); 4) the fairness and impartiality in the treatment; 5) social acceptability of the service supply; 6) the efficiency and economy of the service rendered (Maxwell, 1984, 1470-1472).

The study of Maxwell can be considered suita-ble for responding to the following questions:

a. Is the service physically and temporally

acces-sible to the persons to whom it is addressed (in terms of physical accessibility and time)?

b. Do services, processes and procedures reflect

the community and individual needs?

c. Does every single service allow obtaining the

benefits or providing desired outcomes for in-dividuals or groups of patients?

d. Is the service provided in an unbiased

man-ner between the various categories or groups of patients?

e. Are the conditions for the provision of the

service, the level of protection of privacy, the communication grade with patients, families and assistance team satisfactory?

JDREAM.indd 84 18/01/18 11:03

84

∙ The risks and dangers to patients are brought to the lowest level,

∙ Health care is based on evidence and on good clinical practice.

According to this approach, the concept of clinical governance implies that the manage-ment of power takes place inside and outside the formal decision tree; these decisions arise from the interaction between the various stake-holders. Any person involved in the process becomes the bearer of specific needs and ex-pectations, different scale of priorities and dif-ferent capacity of perception of the results ob-tained (Wright, Hill 2005, 22-23). However, it is interesting to observe that once it is stabilized the process of clinical governance, the problem becomes its integration with all the other ele-ments that constitute the different aspects of the management of health care organizations. Integrated governance is a further concept in-troduced for the first time in England in 2003, with the document entitled: "Governing the NHS: a Guide for NHS Boards (NHS Ap-pointment Commission, 2003). The aim of this document is the integration of the different sec-toral systems of governance (health, clinic, fi-nancial, management, research and infmation) and delete the existing overlays, in or-der to standardize (harmonize) different basal processes. The need for an integrated approach is based on the recognition that working for sectors - in a not shared way - is scattered and unproductive, so it is necessary to develop a unifying methodology that helps the organiza-tions to realize their mission and reach the ob-jectives (Wall, Halligan, Deighan, Cullen, 2002). The concept of integrated governance goes be-yond the corporate governance that is defined as the set of rules and organizational structures by which companies are managed and con-trolled. Health facilities (especially public ones) are considered as a constellation of several complex systems: there is the system of hospital care and the one related to primary care, the system of professional clinicians, and the one of professionals in organization, the system of the most important centers and the one in periph-eries (Wright, Hill, 2005, 25).

The management philosophy of integrated gov-ernance also includes risk management, a methodology employed in health care settings but derived from the financial sector and that,

in essence, involves the management of all those risks that threaten the value of an organi-zation and that involve different aspects and different dimensions of organizational phe-nomenon: strategies, market processes, financial resources, human resources, technologies. However, the application of this methodology in the field of health care, cannot collapse in the

transfer sic et nunc of principles and techniques

designed in the industrial sector, financial or of the ICT (Novaco 2004, 24), although it is clear that even a health care company must deal with many risks that go beyond a particular risk and encompassing any general risks that any organi-zation, regardless of the sector to which they belong, must know how to manage in terms of total quality.

Literature on organization, mainly from North American, was concerned to provide the defini-tion of quality in health care systems and to draw up specific models (Donabedian 1966; Devlin 1990; Charlesworth 1993, 25). In 1984, Maxwell developed a model that includes six fundamental dimensions aimed to obtain effi-cient and effective level of quality in health care: 1) access to services; 2) the significance of collective needs (of the community); 3) the practical effectiveness for the "person" (indi-vidual patients); 4) the fairness and impartiality in the treatment; 5) social acceptability of the service supply; 6) the efficiency and economy of the service rendered (Maxwell, 1984, 1470-1472).

The study of Maxwell can be considered suita-ble for responding to the following questions:

a. Is the service physically and temporally

acces-sible to the persons to whom it is addressed (in terms of physical accessibility and time)?

b. Do services, processes and procedures reflect

the community and individual needs?

c. Does every single service allow obtaining the

benefits or providing desired outcomes for in-dividuals or groups of patients?

d. Is the service provided in an unbiased

man-ner between the various categories or groups of patients?

e. Are the conditions for the provision of the

service, the level of protection of privacy, the communication grade with patients, families and assistance team satisfactory?

84

∙ The risks and dangers to patients are brought to the lowest level,

∙ Health care is based on evidence and on good clinical practice.

According to this approach, the concept of clinical governance implies that the manage-ment of power takes place inside and outside the formal decision tree; these decisions arise from the interaction between the various stake-holders. Any person involved in the process becomes the bearer of specific needs and ex-pectations, different scale of priorities and dif-ferent capacity of perception of the results ob-tained (Wright, Hill 2005, 22-23). However, it is interesting to observe that once it is stabilized the process of clinical governance, the problem becomes its integration with all the other ele-ments that constitute the different aspects of the management of health care organizations. Integrated governance is a further concept in-troduced for the first time in England in 2003, with the document entitled: "Governing the NHS: a Guide for NHS Boards (NHS Ap-pointment Commission, 2003). The aim of this document is the integration of the different sec-toral systems of governance (health, clinic, fi-nancial, management, research and infmation) and delete the existing overlays, in or-der to standardize (harmonize) different basal processes. The need for an integrated approach is based on the recognition that working for sectors - in a not shared way - is scattered and unproductive, so it is necessary to develop a unifying methodology that helps the organiza-tions to realize their mission and reach the ob-jectives (Wall, Halligan, Deighan, Cullen, 2002). The concept of integrated governance goes be-yond the corporate governance that is defined as the set of rules and organizational structures by which companies are managed and con-trolled. Health facilities (especially public ones) are considered as a constellation of several complex systems: there is the system of hospital care and the one related to primary care, the system of professional clinicians, and the one of professionals in organization, the system of the most important centers and the one in periph-eries (Wright, Hill, 2005, 25).

The management philosophy of integrated gov-ernance also includes risk management, a methodology employed in health care settings but derived from the financial sector and that,

in essence, involves the management of all those risks that threaten the value of an organi-zation and that involve different aspects and different dimensions of organizational phe-nomenon: strategies, market processes, financial resources, human resources, technologies. However, the application of this methodology in the field of health care, cannot collapse in the

transfer sic et nunc of principles and techniques

designed in the industrial sector, financial or of the ICT (Novaco 2004, 24), although it is clear that even a health care company must deal with many risks that go beyond a particular risk and encompassing any general risks that any organi-zation, regardless of the sector to which they belong, must know how to manage in terms of total quality.

Literature on organization, mainly from North American, was concerned to provide the defini-tion of quality in health care systems and to draw up specific models (Donabedian 1966; Devlin 1990; Charlesworth 1993, 25). In 1984, Maxwell developed a model that includes six fundamental dimensions aimed to obtain effi-cient and effective level of quality in health care: 1) access to services; 2) the significance of collective needs (of the community); 3) the practical effectiveness for the "person" (indi-vidual patients); 4) the fairness and impartiality in the treatment; 5) social acceptability of the service supply; 6) the efficiency and economy of the service rendered (Maxwell, 1984, 1470-1472).

The study of Maxwell can be considered suita-ble for responding to the following questions:

a. Is the service physically and temporally

acces-sible to the persons to whom it is addressed (in terms of physical accessibility and time)?

b. Do services, processes and procedures reflect

the community and individual needs?

c. Does every single service allow obtaining the

benefits or providing desired outcomes for in-dividuals or groups of patients?

d. Is the service provided in an unbiased

man-ner between the various categories or groups of patients?

e. Are the conditions for the provision of the

service, the level of protection of privacy, the communication grade with patients, families and assistance team satisfactory?

85

f. Are the resources employed in the processes

and in the phase of supplying services, used without waste?

g. Do detailed rules for the provision of the

ser-vice (and those who provide it) meet the securi-ty measures that have to minimize the adverse effects of a treatment?

In any case it is observed that - regardless of the model used - the priorities linked to the re-spective principles depend on the needs and expectations of the parties involved that, in the health sphere, correspond to patients (benefi-ciaries of a service or a specific treatment), to professionals (medical staff and social health), managers (management and administrative staff) and finally to who really pays the service apart from services and performance received (taxpayers) (Wright, Hill 2005, 5-6).

A particular aspect related to health services quality, concerns the management of total

qual-ity (Total Quality Management), defined as a

con-tinuous improvement of quality (Continuous

Quality Improvement) when it addresses to an

or-ganizational effort aimed at improving the overall performance. The key principles that are at the basis of the total quality management, are realized when: (a) the success of the organiza-tion resides in the accession of all its compo-nents to the needs of those who benefit from the service (patients); (b) quality is a consequen-tial effect of the production processes in which the causal interactions are complex but under-standable; c) the personnel involved in the pro-cess is intrinsically motivated to work with ded-ication and keep ethically corrected behaviors; d) the use of simple statistical methods associ-ated with a correct collection and analysis of da-ta, can constitute an effective procedure for the identification and understanding of problems related to operational processes and identifica-tion of risks.

In conclusion, total quality management implies the focus on operations and on expected re-sults, analysis and the consequent identification of the needs of patients, analysis of the varia-tions in processes or in results, the existence of multifunctional working groups for identifying and resolving quality issues, the use of data col-lected in a systematic manner at any point of the problem solving process for high-priority

is-sues, causes, possible solutions and changes, learning and continuous improvement, process

management tools to increase the effectiveness of working groups such as, for example, flowcharts, cause and effect diagrams, brain-storming, benchmarking (Wright, Hill 2005, 8).

3. The clinical risk and the safety of the patient

A correct definition of risk comes from the analysis of risk within the chain of genesis of the damage, with the purpose to clearly distin-guish the different phases that often, in com-mon parlance, are confused by the use of ge-neric terms. The strategy is to start from some

definitions laid down by the Occupational Health

and Safety Management system (OHSAS 18001:

1999). In particular, it is distinguished between: a) hazard, situation or cause that enhances the damage; b) incident, occurrence that may give rise to damage; (c) accident, unexpected event and unfavorable cause of a damage.

These terms describe the stages of the chain by which it is generated a damage: the hazard rep-resents an existing danger, which becomes a potential source of damage when it overlaps with an activity (e.g. the routine activities of a department or a health care facility). Some-times, especially in health care, the link between activities and danger is so narrow that they may not be readily cleaved. This overlap determines the possibility that the danger is translated into an adverse event and this probability is the risk (risk) that may give rise to an incident, followed by a damage (accident). What binds event and damage are often unpredictable and fortuitous factors and very large number of events, which occur in the health and in other sectors without bringing any significant damage, demonstrates the lability of this bond. If the management of risk, in the health sector, is related to systematic processes of identification, assessment and treatment of actual and potential risks, the goal is focused on increment in safety of patients, to

the improvement of the outcome and the

indi-rectly reduction of costs, with a consequent re-duction of preventable adverse events. For this purpose, the health care organizations - as it happens in industries and in other sectors - should analyze adverse events by using rigorous investigation techniques, in order to remove the system errors that are at the basis of such events.

85

f. Are the resources employed in the processes

and in the phase of supplying services, used without waste?

g. Do detailed rules for the provision of the

ser-vice (and those who provide it) meet the securi-ty measures that have to minimize the adverse effects of a treatment?

In any case it is observed that - regardless of the model used - the priorities linked to the re-spective principles depend on the needs and expectations of the parties involved that, in the health sphere, correspond to patients (benefi-ciaries of a service or a specific treatment), to professionals (medical staff and social health), managers (management and administrative staff) and finally to who really pays the service apart from services and performance received (taxpayers) (Wright, Hill 2005, 5-6).

A particular aspect related to health services quality, concerns the management of total

qual-ity (Total Quality Management), defined as a

con-tinuous improvement of quality (Continuous

Quality Improvement) when it addresses to an

or-ganizational effort aimed at improving the overall performance. The key principles that are at the basis of the total quality management, are realized when: (a) the success of the organiza-tion resides in the accession of all its compo-nents to the needs of those who benefit from the service (patients); (b) quality is a consequen-tial effect of the production processes in which the causal interactions are complex but under-standable; c) the personnel involved in the pro-cess is intrinsically motivated to work with ded-ication and keep ethically corrected behaviors; d) the use of simple statistical methods associ-ated with a correct collection and analysis of da-ta, can constitute an effective procedure for the identification and understanding of problems related to operational processes and identifica-tion of risks.

In conclusion, total quality management implies the focus on operations and on expected re-sults, analysis and the consequent identification of the needs of patients, analysis of the varia-tions in processes or in results, the existence of multifunctional working groups for identifying and resolving quality issues, the use of data col-lected in a systematic manner at any point of the problem solving process for high-priority

is-sues, causes, possible solutions and changes, learning and continuous improvement, process

management tools to increase the effectiveness of working groups such as, for example, flowcharts, cause and effect diagrams, brain-storming, benchmarking (Wright, Hill 2005, 8).

3. The clinical risk and the safety of the patient

A correct definition of risk comes from the analysis of risk within the chain of genesis of the damage, with the purpose to clearly distin-guish the different phases that often, in com-mon parlance, are confused by the use of ge-neric terms. The strategy is to start from some

definitions laid down by the Occupational Health

and Safety Management system (OHSAS 18001:

1999). In particular, it is distinguished between: a) hazard, situation or cause that enhances the damage; b) incident, occurrence that may give rise to damage; (c) accident, unexpected event and unfavorable cause of a damage.

These terms describe the stages of the chain by which it is generated a damage: the hazard rep-resents an existing danger, which becomes a potential source of damage when it overlaps with an activity (e.g. the routine activities of a department or a health care facility). Some-times, especially in health care, the link between activities and danger is so narrow that they may not be readily cleaved. This overlap determines the possibility that the danger is translated into an adverse event and this probability is the risk (risk) that may give rise to an incident, followed by a damage (accident). What binds event and damage are often unpredictable and fortuitous factors and very large number of events, which occur in the health and in other sectors without bringing any significant damage, demonstrates the lability of this bond. If the management of risk, in the health sector, is related to systematic processes of identification, assessment and treatment of actual and potential risks, the goal is focused on increment in safety of patients, to

the improvement of the outcome and the

Biopolitics, Risk and Organization in Health Care

86

In U.S., the publication of the report: To err is

human: building a safer health care system

(Washing-ton, Institute of Medicine, 2000) allowed the starting of a series of researches on human er-rors in medicine. The report outlines a compre-hensive strategy among government, market, patients and health services that try to reduce errors in medicine by inviting the Congress to realize a National-popular center for safety of the patients, who develop new tools and sys-tems needed to solve this problem.

This turning point significantly contributes to analyze the relationship between ICT and risk management as part of the more general situa-tion regarding the quality and safety of services (Esteves, Joseph, 2008). ICT are, in fact, pow-erful tools to support the organizational

struc-ture, decision-making processes (Clinical Decision

Support System, Health Technology Assessment) and

the monitoring of risk governance processes

(Clinical Data Repository, Electronic Medical Record)

(Friedman, Halpern, Fackler 2008, 69-76). However, this approach must take into account the transition from a purely reactive system (management of non-compliance, emergency management etc.) to a predominantly pro-active and preventive system.

A further aspect is the increasing attention on safety at all organizational levels. Adverse events are undoubtedly a problem of quality of care, and to that extent, they have a purely clin-ical relevance, but also have economic and so-cial implications linked to the costs incurred by the health care facility that cause a general problem, but not less relevant, that is the loss of confidence of the population against the health service.

In this perspective, the safety of patients, as-sumes an importance that involves all phases and aspects of the organization. The lack of in-tegration between the different organizational levels or the predominance of some over oth-ers, determine the loss of essential components of clinical risk management that lead to a partial vision and therefore not fully reliable.

If it is true that the primary purpose of a health care company is the protection of the health of patients and population, it is also evident that

the strategies of risk management must be mainly

oriented on prevention and risk management in accordance with the principle of Ippocrate

primum non nocere (Reason 2004, 25).

In recent years, the safety of the patients was placed as a priority of the health services in many countries and this centrality could not be attributed to the occurrence of particular events, but rather to the dissemination of re-ports and epidemiological studies relating to iat-rogenic damage. In the face of this importance, the management of risk becomes the strategic

function of a learning organization model, i.e. an

organization capable of sharing its knowledge, learn through participation in the various expe-riences and improve through the dissemination of new knowledge and culture technical-professional that characterizes it.

The cultural approach to the safety of the pa-tients has a relief that cannot be overlooked, especially if you consider its bond with what is the vision of "Error" on which it is based. The determinant is found, in fact, in the passage from a vision of the error, as cause of system failure, to the vision of error generated by the complexity of the system itself.

The scientific and technological progress, the exponential process of specialization of medical sciences and the increasing organizational com-plexity, contribute to the increase in medical er-rors, although it has increased the awareness of the rights over time and thus the demand for greater transparency, clarity, accessibility, intel-ligibility and safety (Gainotti, Poppi 2004, 61). The debate on the issue is very intense and rich of paradoxes, "on one hand, no century has known such overwhelming progress in biomed-ical treatments and pharmacologbiomed-ical properties as the twentieth century […], and everything suggests that the increasing pace of innovations diagnostic, therapeutic and rehabilitative ser-vices will continue. However, now as never, the uncertainties and suspicions are deep and wide-spread in fields such as science, basic health practices and in the chance of healing, as well as to ensure equal health care practice for not guaranteed patients "(Ardigo, 1997). According to this claim, the success of medicine is at the basis of its own weakness. Nowadays, failures that occur in diseases that were incurable in the past, are no longer perceived as tolerable but become errors. In addition, the hard and visible dispute between patient and clinician in the health care environment is becoming physiolog-ical. Today, patients expect to be guaranteed in terms of security and they demand to be

in-Biopolitics, Risk and Organization in Health Care

86

In U.S., the publication of the report: To err is

human: building a safer health care system

(Washing-ton, Institute of Medicine, 2000) allowed the starting of a series of researches on human er-rors in medicine. The report outlines a compre-hensive strategy among government, market, patients and health services that try to reduce errors in medicine by inviting the Congress to realize a National-popular center for safety of the patients, who develop new tools and sys-tems needed to solve this problem.

This turning point significantly contributes to analyze the relationship between ICT and risk management as part of the more general situa-tion regarding the quality and safety of services (Esteves, Joseph, 2008). ICT are, in fact, pow-erful tools to support the organizational

struc-ture, decision-making processes (Clinical Decision

Support System, Health Technology Assessment) and

the monitoring of risk governance processes

(Clinical Data Repository, Electronic Medical Record)

(Friedman, Halpern, Fackler 2008, 69-76). However, this approach must take into account the transition from a purely reactive system (management of non-compliance, emergency management etc.) to a predominantly pro-active and preventive system.

A further aspect is the increasing attention on safety at all organizational levels. Adverse events are undoubtedly a problem of quality of care, and to that extent, they have a purely clin-ical relevance, but also have economic and so-cial implications linked to the costs incurred by the health care facility that cause a general problem, but not less relevant, that is the loss of confidence of the population against the health service.

In this perspective, the safety of patients, as-sumes an importance that involves all phases and aspects of the organization. The lack of in-tegration between the different organizational levels or the predominance of some over oth-ers, determine the loss of essential components of clinical risk management that lead to a partial vision and therefore not fully reliable.

If it is true that the primary purpose of a health care company is the protection of the health of patients and population, it is also evident that

the strategies of risk management must be mainly

oriented on prevention and risk management in accordance with the principle of Ippocrate

primum non nocere (Reason 2004, 25).

In recent years, the safety of the patients was placed as a priority of the health services in many countries and this centrality could not be attributed to the occurrence of particular events, but rather to the dissemination of re-ports and epidemiological studies relating to iat-rogenic damage. In the face of this importance, the management of risk becomes the strategic

function of a learning organization model, i.e. an

organization capable of sharing its knowledge, learn through participation in the various expe-riences and improve through the dissemination of new knowledge and culture technical-professional that characterizes it.

The cultural approach to the safety of the pa-tients has a relief that cannot be overlooked, especially if you consider its bond with what is the vision of "Error" on which it is based. The determinant is found, in fact, in the passage from a vision of the error, as cause of system failure, to the vision of error generated by the complexity of the system itself.

The scientific and technological progress, the exponential process of specialization of medical sciences and the increasing organizational com-plexity, contribute to the increase in medical er-rors, although it has increased the awareness of the rights over time and thus the demand for greater transparency, clarity, accessibility, intel-ligibility and safety (Gainotti, Poppi 2004, 61). The debate on the issue is very intense and rich of paradoxes, "on one hand, no century has known such overwhelming progress in biomed-ical treatments and pharmacologbiomed-ical properties as the twentieth century […], and everything suggests that the increasing pace of innovations diagnostic, therapeutic and rehabilitative ser-vices will continue. However, now as never, the uncertainties and suspicions are deep and wide-spread in fields such as science, basic health practices and in the chance of healing, as well as to ensure equal health care practice for not guaranteed patients "(Ardigo, 1997). According to this claim, the success of medicine is at the basis of its own weakness. Nowadays, failures that occur in diseases that were incurable in the past, are no longer perceived as tolerable but become errors. In addition, the hard and visible dispute between patient and clinician in the health care environment is becoming physiolog-ical. Today, patients expect to be guaranteed in terms of security and they demand to be

in-JDREAM.indd 86 18/01/18 11:03